Ursachenermittlung

Ursachenermittlung is a systematic process to identify the fundamental causes of an incident, defect, or problem. The goal is to distinguish symptoms from root causes and to understand how organizational, technical, human, and external factors interact. It is used in safety engineering, quality management, process improvement, IT incident handling, and healthcare to prevent recurrence and to support learning and continuous improvement.

Common methods include the Five Whys, Ishikawa (fishbone) diagrams, Fault Tree Analysis (FTA), and Failure Mode and Effects Analysis (FMEA). Event tracing, data collection, expert interviews, and process mapping support the analysis. The approach emphasizes evidence-based reasoning and aims to uncover systemic factors rather than assigning blame to individuals.

Typical workflow involves defining the problem, collecting data, identifying potential causes, testing and validating root causes, and developing preventive and corrective actions. These actions are designed to address underlying system weaknesses and are followed by implementation and monitoring of their effectiveness. Clear documentation and traceability are essential to ensure learnings are shared and actions are verifiable.

Limitations include the complexity of modern systems, where multiple factors may contribute and interact, as well as incomplete information, cognitive biases, and time pressures. Some events may resist a single, definitive root cause. Nevertheless, Ursachenermittlung remains a central tool for improving safety, reliability, and quality by addressing underlying vulnerabilities rather than only their symptoms.